Treatment Recommendations for People Who Act Out Their Dreams While Asleep

Summary: REM sleep behavior disorder, or parasomnia, affects more than 80 million people worldwide. The disorder causes sufferers to experience nightmare-like violent dreams. Sufferers act on their dreams while sleeping, often resulting in violent or dangerous sleep behaviors and injuries. Researchers propose new guidelines, including medical and pharmacological recommendations, to help curb symptoms of parasomnia and promote healthier sleep.

Source: American Academy of Sleep Medicine

A new clinical practice guideline developed by the American Academy of Sleep Medicine provides recommendations for the management of REM sleep behavior disorder in adults.  

The guideline, available online as an accepted paper in the Journal of Clinical Sleep Medicine, updates the AASM’s previous guidance published in 2010. Several clinical trials conducted in the last decade have contributed new evidence to the published literature, providing additional support for the recommendations.  

“REM sleep behavior disorder is common, affecting more than 80 million people worldwide,” said lead author Dr. Michael Howell, chair of the AASM task force and a professor and division head of sleep medicine in the department of neurology at the University of Minnesota in Minneapolis.

“This clinical practice guideline provides clinicians with insight on how best to prevent sleep-related injury and how to provide patients with a risk assessment for neurological disease. The task force assembled by the AASM diligently reviewed thousands of clinical studies to provide an up-to-date guideline for clinicians managing REM sleep behavior disorder.” 

REM sleep behavior disorder is classified as a parasomnia, a group of sleep disorders involving undesirable physical events or experiences that happen while falling asleep, sleeping, or waking from sleep. REM sleep is characterized by rapid eye movements and dream activity, and it normally involves skeletal paralysis.

This paralysis — or muscle atonia — is lost in REM sleep behavior disorder, causing individuals to act out their dreams with potentially injurious behaviors. These dreams tend to be unpleasant, action-filled, or violent, with the dreamer being confronted, attacked, or chased by unfamiliar people or animals.

The symptoms of REM sleep behavior disorder are often ignored for years, usually until an injury occurs to the dreamer or the bed partner. REM sleep behavior disorder often occurs due to an underlying neurological disorder, such as dementia with Lewy bodies, Parkinson’s disease, multiple system atrophy, narcolepsy, or stroke. 

The guideline provides recommendations for specific medications, such as clonazepam and immediate-release melatonin, that clinicians should consider when treating REM sleep behavior disorder in adults.

All of the recommendations are conditional, requiring the clinician to use clinical knowledge and experience, and to strongly consider the patient’s values and preferences, to determine the best course of action.

Treatment options also depend on whether the case of REM sleep behavior disorder is isolated, secondary to another medical condition, or drug induced.  

This shows a man sitting at a dark window
REM sleep behavior disorder is classified as a parasomnia, a group of sleep disorders involving undesirable physical events or experiences that happen while falling asleep, sleeping, or waking from sleep. Image is in the public domain

The guideline also emphasizes the need for patients to maintain a safe sleeping environment to prevent injuries while sleeping. The guideline suggests removing bedside objects that could easily injure someone while asleep. Sharp furniture should be moved away, or their edges should be padded; a soft carpet or mat should be placed next to the bed in case of sudden falls.

To reduce the risk of injuries, people with severe REM sleep behavior disorder should be advised to sleep separately from their partners until treated.  

To develop the guideline, the AASM commissioned a task force of sleep medicine clinicians with expertise in REM sleep behavior disorder. They crafted the clinical practice recommendations based on a systematic review of the literature and an assessment of the evidence according to the GRADE process, taking into consideration the quality of evidence, beneficial and harmful effects, patient values and preferences, and resource use.  

The guideline was endorsed by the International RBD Study Group, Project Sleep, and Wake Up Narcolepsy, and it was affirmed by the American Academy of Neurology and the American Geriatrics Society. 

About this sleep research news

Author: Sydney Preston
Source: American Academy of Sleep Medicine
Contact: Sydney Preston – American Academy of Sleep Medicine
Image: The image is in the public domain

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  1. I lived with a person who suffered frequent night terrors where she acted out violent scenarios related to traumatic events, which put both of us at great risk of physical harm. I was able to use hypnosis techniques whilst she was deep in the dream, and also to draw her into or out of the dream. We found a simple, calm counting down from ten enabled a change of consciousness. Sometimes to wake her, I would have to count her to sleep, even though she was deep in an episode, because she didn’t know she was asleep. After an episode, we could debrief and discuss strategies of approaches she could take when next in the dream. Initially, the dream was repeatedly the same each time. As we worked to resolve it, aspects of the dream would change, until a terrifying motif of trauma would be faced, challenged and subdued until finally accepted with love. It took six months of intensive work to resolve the trauma issues and end the violent episodes, which took a massive toll on my health and I was off work for a while, but I saw it as the only solution. Her doctor’s only suggestion was sleeping pills. Attending professional trauma counselling is recommended, but a clinician cannot be at the bedside day and night, so I imagine the process might take much longer than six months. Medical suppression of the condition might seem the painless solution – or the only approach available at a time when mental health waiting lists are two years long, and no survival techniques are offered to sufferers and their families, but it is not a cure. I’m not suggesting anyone seek out a hypnotist either, by the way, or follow the same path I took without help. I hope this message does not come across as reckless, but my experience leads me to believe night terrors occur because the subconscious is demanding the trauma be addressed, and because your subconscious knows it is the optimum time to address it. Such is not the time to suppress the condition, but to recognise it is the time to face it and heal.

  2. I agree with Ms. Singer’s feedback. This article also completely leaves out PTSD as a reason for these sleep disturbance. As a psychotherapist specializing in trauma and relationship therapies, I frequently hear about this as a part of the symptom set that clients present, whether from childhood/developmental or adult trauma. These nightmares generally literally or symbolically represent aspects of the unresolved trauma. There are cognitive-behavioral interventions that tend to be quite effective in minimizing or stopping these from continuing while the client works in therapy sessions to resolve the intrusive memory material.

  3. I second the previous comment on Clonazepam. Not only does it disrupt restorative sleep, but long term use of any benzodiazapine comes with risks of cognitive decline, possibly permanent. My own personal experience was with a partner who had taken Clonazepam for years for his REM sleep disorder and had developed extreme long and short term memory problems, brain fog and other cognitive deficits, as well as physical issues such as ED. Now, 5 years after withdrawing and lots of restorative treatment he’s doing better, but still struggles some with memory and cognitive issues. Long term Clonazepam should never be standard of care for REM sleep disorder, or anything else for that matter. The treatment is worse than the disorder.

  4. Clonazepam destroys stage 4 sleep, it is NOT a long term treatment option. You get knocked out, you do not sleep–Your patient will report being unconscious for 8hrs but still be exhausted. It will eventually damage the heart. Clonazepam should only be used in short bursts, not for YEARS. These recommendations are ill advised and should not be used for a chronic life long illness like REM Sleep Behavior Disorder.

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